Nursing Elites

1. What is the correct intervention for a patient experiencing anaphylaxis?

• A. Administer epinephrine
• B. Provide oxygen
• C. Monitor airway
• D. All of the above

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

2. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?

• A. Ensure the client has cotton bedding
• B. Keep the oxygen equipment away from heat sources
• C. Use wool blankets to ensure warmth
• D. Allow the client to use electronic devices near the oxygen supply

Correct answer: B

Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.

3. What are the nursing interventions for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Administer antiplatelet therapy
• C. Check for signs of DVT and provide anticoagulation
• D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

4. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client with pneumonia who had new onset of confusion
• B. A client with diabetes who had low blood sugar overnight
• C. A client with a leg fracture who needs pain medication
• D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

5. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?

• A. Increase the client's oxygen flow rate
• B. Obtain the client's vital signs
• C. Administer an antibiotic
• D. Notify the provider

Correct answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

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